<form id="edit-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Presentation_patient_char_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-presentation_patient_char_id" data-rule="required" data-source="presentation/patient/char/index" class="form-control selectpage form-control" name="row[presentation_patient_char_id]" type="text" value="{$row.presentation_patient_char_id}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Meddra_version_for_medical_history')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-meddra_version_for_medical_history" class="form-control form-control" name="row[meddra_version_for_medical_history]" type="number" value="{$row.meddra_version_for_medical_history}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Medical_history_disease_surgical_procedure_etc_meddra_code')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-medical_history_disease_surgical_procedure_etc_meddra_code"
                   data-source="meddra/index" data-show-field="en" data-show-field="en" data-primary-key="code"
                   class="form-control form-control" name="row[medical_history_disease_surgical_procedure_etc_meddra_code]" type="text" value="{$row.medical_history_disease_surgical_procedure_etc_meddra_code}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Start_date')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-start_date" class="form-control datetimepicker form-control"  data-date-format="YYYY-MM-DD" data-use-current="true" name="row[start_date]" type="text" value="{$row.start_date}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Continuing')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-continuing" class="form-control form-control" name="row[continuing]" type="text" value="{$row.continuing}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('End_date')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-end_date" class="form-control datetimepicker form-control"  data-date-format="YYYY-MM-DD" data-use-current="true" name="row[end_date]" type="text" value="{$row.end_date}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Comments_content')}:</label>
        <div class="col-xs-12 col-sm-8">
            <textarea id="c-comments_content" class="form-control editor form-control" rows="5" name="row[comments_content]" cols="50">{$row.comments_content}</textarea>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Family_historyd')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-family_historyd" class="form-control form-control" name="row[family_historyd]" type="text" value="{$row.family_historyd}">
        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-success btn-embossed disabled">{:__('OK')}</button>
            <button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
        </div>
    </div>
</form>
